Provider Demographics
NPI:1295795771
Name:DAVIS, DAMON C (MD)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:888-484-3258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27240207R00000X
IN01065572A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ501769Medicaid
IN200949600Medicaid
AZAZ0710160OtherBC/BS OF AZ
AZH30322Medicare UPIN
AZAZ0710160OtherBC/BS OF AZ
IN200949600Medicaid
AZZ38283Medicare PIN
AZ68283Medicare PIN
IN267030XMedicare PIN
AZ101930Medicare PIN
AZ101916Medicare PIN